Reproductive Health

BioMed Central

Open Access

Review

Limits to modern contraceptive use among young women in
developing countries: a systematic review of qualitative research
Lisa M Williamson*1, Alison Parkes1, Daniel Wight1, Mark Petticrew2 and
Graham J Hart3
Address: 1MRC Social and Public Health Sciences Unit, 4 Lilybank Gardens, Glasgow, G12 8RZ, UK, 2Public and Environmental Health Research
Unit, Keppel Street, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK and 3Centre for Sexual Health and HIV Research,
Research Department of Infection and Population Health, University College London, Mortimer Market Centre, off Capper Street, London, WC1E
6JB, UK
Email: Lisa M Williamson* - lisa@sphsu.mrc.ac.uk; Alison Parkes - alison-p@sphsu.mrc.ac.uk; Daniel Wight - danny@sphsu.mrc.ac.uk;
Mark Petticrew - Mark.Petticrew@lshtm.ac.uk; Graham J Hart - GHart@gum.ucl.ac.uk
* Corresponding author

Published: 19 February 2009
Reproductive Health 2009, 6:3

doi:10.1186/1742-4755-6-3

Received: 10 November 2008
Accepted: 19 February 2009

This article is available from: http://www.reproductive-health-journal.com/content/6/1/3
© 2009 Williamson et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background: Improving the reproductive health of young women in developing countries requires access
to safe and effective methods of fertility control, but most rely on traditional rather than modern
contraceptives such as condoms or oral/injectable hormonal methods. We conducted a systematic review
of qualitative research to examine the limits to modern contraceptive use identified by young women in
developing countries. Focusing on qualitative research allows the assessment of complex processes often
missed in quantitative analyses.
Methods: Literature searches of 23 databases, including Medline, Embase and POPLINE®, were
conducted. Literature from 1970–2006 concerning the 11–24 years age group was included. Studies were
critically appraised and meta-ethnography was used to synthesise the data.
Results: Of the 12 studies which met the inclusion criteria, seven met the quality criteria and are included
in the synthesis (six from sub-Saharan Africa; one from South-East Asia). Sample sizes ranged from 16 to
149 young women (age range 13–19 years). Four of the studies were urban based, one was rural, one semirural, and one mixed (predominantly rural). Use of hormonal methods was limited by lack of knowledge,
obstacles to access and concern over side effects, especially fear of infertility. Although often more
accessible, and sometimes more attractive than hormonal methods, condom use was limited by association
with disease and promiscuity, together with greater male control. As a result young women often relied
on traditional methods or abortion. Although the review was limited to five countries and conditions are
not homogenous for all young women in all developing countries, the overarching themes were common
across different settings and contexts, supporting the potential transferability of interventions to improve
reproductive health.
Conclusion: Increasing modern contraceptive method use requires community-wide, multifaceted
interventions and the combined provision of information, life skills, support and access to youth-friendly
services. Interventions should aim to counter negative perceptions of modern contraceptive methods and
the dual role of condoms for contraception and STI prevention should be exploited, despite the challenges
involved.

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sexually active women aged 15– 24 years in sub-Saharan Africa use contraception but only 8% use a non-barrier method [10]. uptake is generally much lower than in developed countries [5]. use (or non-use). sex education and access to services. We also searched the websites of a number of relevant reproductive health organisations. pregnancy. 75% of young women report having had sex by age 20 [9].12]. and increased sexual activity prior to marriage [5.000 live births (in sub-Saharan Africa. with a widening gap between sexual debut and age of marriage. is central to the World Health Organisation (WHO) work on improving maternal health and is core to achieving the Millennium Development Goal on this [3]. The review was refined to include only qualitative research (studies which used qualitative data collection methods. We undertook a systematic review of qualitative research on young women's own views of their contraceptive choices to examine factors limiting modern method use. and at least one quarter of the study's results were on uptake. One quarter of the estimated 20 million unsafe abortions and 70.com/content/6/1/3 However. and used qualitative methods of analysis). Citation searches of key authors were conducted. Focusing on qualitative research allows the assessment of complex processes. For example.6]. Premarital exposure to pregnancy risk has increased. However. in turn. We originally planned to include quantitative research in our review. so that women can avoid unwanted pregnancy. and negative social norms around premarital sexual activity and pregnancy [11. focused on the 11–24 years age group and females (or presented female data separately from male). included the young women's views in their own words.2]. reducing child mortality and eradicating extreme poverty [1. 6:3 Background Improving reproductive health is central to achieving the Millennium Development Goals on improving maternal health. contraceptive.000 abortion related deaths each year occur among women aged 15–19 years. choice or discontinuation of contraceptives (including all non-permanent Page 2 of 12 (page number not for citation purposes) . http://www. and journals. but the high number of papers we sourced (19551 references from developing and developed countries. and in the US 54% of 15–19 year old females reported condom use at most recent sex. This requires that women have access to safe and effective methods of fertility control. Table 2 shows the inclusion/exclusion criteria.Reproductive Health 2009. it is estimated that 14 million unintended pregnancies occur every year. although there is considerable variation between countries [5.reproductive-health-journal. could be prevented by use of effective contraception [1]. and although there is considerable variation between countries. included qualitative research. Although there has been a systematic review of qualitative research on young people's sexual behaviour [15]. Mavranezouli and McGinn [4] suggest that the choice of implant rather than oral or injectable contraceptives could have a big impact on unintended pregnancy in this age group.7]. Only one of these reviews focused on adolescents. By combining the findings from such studies we can demonstrate how themes may be common across settings and contexts. maternal mortality is high. Included studies were published between 1970 and 2006. few sexually active adolescents in developing countries use modern contraceptive methods such as oral contraceptives and condoms. compared with 12% in Mali. improves the reliability and validity of the conclusions drawn. this figure reaches 920) [2]. The promotion of family planning. 69% of adolescent women in a UK study reported use of a modern contraceptive method at most recent sex. risk misperceptions. often missed in quantitative studies [13. safe sex and choice terms (Table 1). greater promotion of any modern method has to be informed by better understanding of why uptake is so low among adolescents in the first place. and data validity is often poor [8]. Methods Table 1 shows the bibliographic databases. it is estimated that 37% of unmarried. Searches combined adolescent. This. It is estimated that 90% of abortion-related and 20% of pregnancy-related morbidity and mortality. Hubacher. Reported sexual activity among adolescents in developing countries is generally high. In developing countries. and neither focused exclusively on qualitative research nor adopted systematic review methodology to critically appraise the included research studies. compared with 21% in Tanzania [5]. Full details of the search strategy are available from the first author. One in three women give birth before age 20 and pregnancy-related morbidity and mortality rates are particularly high in this group [2]. of which 4042 were potentially relevant) made this impossible. along with 32% of maternal deaths. searched for literature from 1970–2006. and the assessment of study quality allows the selection of the most reliable and valid findings. In sub-Saharan Africa. we know of no systematic reviews of qualitative studies specific to contraceptive use to determine the full extent of the difficulties faced by young women in accessing modern methods.14]. Overall. Previously identified limits to contraceptive use among adolescents in developing countries include lack of knowledge. with almost half occurring among women aged 15–24 years [4]. In sub-Saharan Africa. placing young women at increased risk when they are most socially and economically vulnerable. with 440 deaths per 100. and this age group is twice as likely to die in childbirth as women aged 20 or over [2].

Sosig. King's Fund Database. Implanon/Norplant. Index to Theses. Database of Abstracts of Reviews of Effects). and the World Health Organisation). The latter are the focus of this paper. girl/girls Choice terms (used as limits where necessary) Choice/choose. young woman/young women. 47 studies were identified for inclusion in the review. CSA websites. Journal of Adolescence. interpretation and conclusions) (Table 3).com. Two of the authors (LW and AP) independently appraised each study. young people/young adults.reproductive-health-journal. knowledge. ERIC. combined pill (oestrogen and progestogen)/progestogen only pill. withdrawal/ pulling out. Harden et al [26].Reproductive Health 2009.uk. clear detail on recruitment. Digital Dissertations. South America. teen/teenage/teenager. abortion. Planned Parenthood. In interpreting rather Page 3 of 12 (page number not for citation purposes) . Depoprovera/Depo-Provera/Noristerat. diaphragm/cervical cap/spermicide – foam. and Oceania excluding Australia and New Zealand [16]. Asia excluding Japan and Hong Kong.17-24].ac. As a result we used approaches that have been developed and published by researchers elsewhere. cream. satisfaction methods).ac. Search terms Contraceptive terms Contraceptive/contraception. pregnancy/pregnant. NHS EEDS database (via CRD).uk. practice. Hand searches Journal of Family Planning and Reproductive Health Care (formerly British Journal of Family Planning). Journal of Adolescent Health. intrauterine device (IUD)/intrauterine system (IUS)/coil. and International Family Planning Perspectives. Studies were assessed on eight criteria relating to the extent to which they included: adequate description of their aims. COPAC (including British Library Catalogue). young female. and McDermott and Graham [27]. and a number of reviews using this approach have been published [25-27. jelly. Population Council. HMIC. Studies that focused exclusively on pregnancy. and those published in languages other than English. MEDLINE. Contraception. switching. Developing countries were defined as those in the areas of Africa. utilise/utilize. young people/young adults. HELMIS. persona/fertility awareness/rhythm method. Meta-ethnography allows the development of a broader perspective while maintaining the specificity of individual studies. behaviour/behaviour. POPLINE®. fpa. We employed quality assessment criteria based on those developed by Attree and Milton [25]. Web of Science – Social Science Citation Index/Science Citation Index. 6:3 http://www. decision making. background and context. OCLC PapersFirst. the Caribbean. attitude. morning-after-pill/Levonorgestrel/Yuzpe regimen. acceptability/acceptance. Websites (Omni. PychINFO. International Women's Health Coalition. Google. CINAHL. Sociological Abstracts. the sample and data collection. The abstracts (or papers where no abstracts were available) of 4042 papers were reviewed and 3975 were excluded because they were not qualitative.com/content/6/1/3 Table 1: Review search strategy Databases ASSIA. or did not include young women's own reports of use. Central America. the Guttmacher Institute. sexual abstinence/abstain (include limit – sex). topic or population. compared and discussed differences. safe sex/unsafe sex/safer sex. In total. EMBASE. and appropriate data analysis and interpretation (including presentation of sufficient original data and integration of data. and agreed on the final appraisal for each. Cochrane Library (Central Register of Controlled Trials. 35 from developed countries and 12 from developing countries. sexual debut or sexual behaviour. Health Technology Assessment Database. Reproductive Health Matters. Database of Systematic Reviews. had an irrelevant focus. use/nonuse/usage.29-32] so this was the approach we adopted. douching Adolescent terms Adolescent/adolescence. Meta-ethnography is one method of qualitative data synthesis [28]. reproductive/reproduction. United Nations Population Fund. HDA. ChildData. were also excluded. HEBS. protected intercourse/unprotected intercourse/unprotected sex/protected sex. (dis)continue/(dis)continued/(dis)continuing/(dis)continuation. birth control. condom/Femidom/prophylactic/ chemoprophylaxis/barrier method. family planning/planned parenthood. Perspectives on Sexual and Reproductive Health (formerly Family Planning Perspectives). Association of Reproductive Health Professionals. Child Trends. abstinence. uptake. There is considerable debate around the systematic review of qualitative research and the methods by which it should be appraised and synthesised [13.

Reproductive Health 2009. Pre-1970 Studies with focus on populations aged 25 years and over. and to demonstrate that these and the conclusions are grounded in the data? Is there clear integration of the data. implant. Sex Study design Male only. number of perspectives on individual contraceptive methods sexual partners. and how sampling and recruitment were conducted? Are exclusions and refusals accounted for or described? Data collection Is there a clear description of the research methodology used? This should include description of the means of data collection. Interview. book reviews. Language Written in English All other languages Relevance One quarter to all of the study's results relate to Less than one quarter of the study's results contraceptive use. last three months. injection. Measures and episodes of contraceptive use Studies reporting contraceptive use at any episode (e. diaphragm/cap. last month. and studies were only included if data for the 11– 19 year age group were shown separately).g. and quantitative methods of analysis). and spermicides). and have used qualitative methods of analysis).g. use.reproductive-health-journal. always. and studies with dichotomous or multiple measures (e.control (male and female sterilisation). and methodological papers. focus group. Studies on natural or traditional contraceptive methods (withdrawal. Female (or female data presented if studies include males and females). the analysis was conducted. any use or methods specified by respondents). age of sexual debut. male condom. interpretation and conclusions? Are the study context and sample considered in the findings? Reliability/validity Is there evidence that the reliability and validity of the analysis has been addressed? *Adapted from McDermott and Graham (2005) [27]. HIV or other STI prevention. and justification for the study focus? Context Is the context/setting of the research adequately described? Are the circumstances under which the research was carried out reported? Sampling/recruitment Is there a clear description of the sample. Is how. literature reviews.com/content/6/1/3 Table 2: Inclusion/exclusion criteria Criteria Inclusion Exclusion Date Age 1970–2006 11–24 years (11–19 years were the main focus. predetermined or fixed responses. female condom. medical contraindications. only. Editorials.g.g. and periodic abstinence). Contraceptive use Uptake. choice or discontinuation Studies focused exclusively on pregnancy. Page 4 of 12 (page number not for citation purposes) . never). resource and policy documents. Qualitative research (studies which used qualitative data collection methods. first or last sexual intercourse). include the young women's views in their own words. of any timescale (e. sometimes. ever). Locations All countries (studies from developing and developed countries were reviewed separately). last year. Quantitative research (studies which used quantitative data collection methods. including the size and characteristics of the sample. bibliographies. of contraceptive use as main focus. as well as by whom. user abstinence. 6:3 http://www. IUD/IUS. of consistent use (e. data collection was conducted reported? Data analysis Is there a clear description of the data analysis method and process? Again this should include description of how. natural family planning. and by whom. relate to contraceptive use Table 3: Quality Assessment Criteria* Criteria Aims Background Clear statement of the aims or research questions of the study Explicit connection to existing theory or literature. and participant observations studies. Contraceptive methods All non-permanent contraceptive methods Studies of permanent solutions to fertility (contraceptive pill – combined and progestogen. (including condom use for pregnancy prevention). Does the study include a comprehensive literature review? Is there sufficient explanation of. non-use. Data interpretation Is there a clear discussion of the research findings? Does the study present sufficient original data to support the findings.

and access to modern contraceptives The majority of young women in each study reported receiving little sex or contraceptive education from parents. In the 'lines-of-argument synthesis' these were translated into five main categories. young women suggested that access to modern methods was not a problem [38].43. Although difficulties accessing contraceptives was not directly addressed in the Vietnamese study. presented here and illustrated with representative quotes from the original papers. and one was mixed (predominantly rural). and only two of the twelve young women in the study had ever used a modern method [41]. This process of synthesis requires repeat reading and constant comparison of each of the studies included in the review." (Young woman. which was considered too sensitive a topic to talk about. The characteristics of the seven studies included in the synthesis are shown in Table 4[38-44].reproductive-health-journal. There was a general misperception that you only had to take the pill when having sex: "I take a pill when I know my boyfriends is coming and we probably going to make love. Sometimes you may challenge them and find that you use words which may hurt them. South Africa. South Africa. Studies were first reviewed to identify key themes. you find they refuse to help you." (Young woman. I sometimes forgot to take it before we make love so I take it after we made love. each individual empirical study [28]. Many thought that they could not get pregnant at first sex. Four of the studies were urban based. Of these. which goes beyond. By identifying the key themes.40. Sample sizes ranged from 16 to 149 with 387 young women in total (there were also five further focus group discussions (FGD) for which the number of participants was not reported).42-44]: "We just feel ashamed but we don't challenge them.43]. but maintains the specificity of. five did not include sufficient original data to support their authors' interpretations. The synthesis highlights that the young women had inaccurate perceptions of pregnancy risk. 6:3 than simply aggregating the data. keeping the study context in mind.41]. prevention. In this." (Young woman. page 65) [43]. Table 5 shows the themes identified in each paper (ticks indicate that the theme was addressed in the paper and crosses indicate that it was not). one was rural. it's just go through. Two studies focused solely on a particular high-risk group of young women who had experienced abortions [39. Then. This was partly because of the distance to these [40. which the young women often felt unable to request: "There is nothing explained to us. or if they had sex standing up or infrequently [38. broader understanding of the issue. or even sex in general. These were then organised in tabular form to compare themes across studies. 1. Any education they did receive often simply reinforced common misperceptions http://www. all the studies suggested that young women had limited knowledge of how they worked or how to use them properly. page 67) [43]. but health services were considered inaccessible in most of the studies. The nurses always look busy and we are afraid to ask questions. the similarities and differences in the findings of individual studies were examined to develop a new. and three included only females. a re-conceptualisation of key themes aims to synthesise and extend the findings of individual component studies [28]. and one each from Nigeria and Mali) and one was from South-East Asia (Vietnam). some described being pressurised by mothers and nurses to start contraception or use particular methods [44].41-44].39.44]. page 113) [44]. South Africa. five included only 13–19 year olds. Results Of the 12 studies from developing countries which met the inclusion criteria. health services or elsewhere. but mainly because young women perceived services to be catered principally for married women and they had significant fears of receiving a negative reception from clinic staff [39. The majority of the young women (where reported) were sexually active and unmarried. This was rarely accompanied by proper guidance on use. two from Tanzania. Even though young women were generally aware of modern hormonal contraceptive methods. Page 5 of 12 (page number not for citation purposes) . Knowledge of pregnancy risk. discussions and conclusions and were excluded [33-37].Reproductive Health 2009. including changes over the monthly cycle. six were from sub-Saharan Africa (two from South Africa. then the next time you go there. what method do you want and if it's an injection they will inject you. one was semi-rural. the studies can be translated into one another by examining their similarities and contradictions. it was clear that young women were rarely provided with adequate information about modern contraceptives.39. In Mali. to answer the review question about limits to modern contraceptive use reported by young women in developing countries. In contrast.com/content/6/1/3 of modern contraceptives [38. a 'lines-of-argument synthesis' was developed.

a family planning clinic. none (6) 116 sexually active Marital status not reported All female Aged 15–19 years 25 still in school (rest employed as housegirls. Dar es Salaam (urban). Nigeria (urban) Sample were selected from a range of areas of residence Focus group discussions Rasch et al (2000) To understand the experiences of adolescent girls with illegally induced abortion 51 Dar es Salaam. primary/secondary (19). secondary (79). Songea) (all but one rural) Individual interviews Kiluvia & Tembele (1991) Nguyen. South Africa (rural) Sample from an antenatal clinic. knowledge and behaviour with respect to family planning and child spacing 141 in 16 focus group discussions (FGD) Bamako and Sikasso. a postnatal ward. Tanzania (urban) Hospital sample (pregnant and admitted to hospital with incomplete. Liamputtong & Murphy (2006) To examine young people's knowledge and practice of contraceptives 16 Ho Chi Minh City. induced abortion) Individual interviews Richter & Mlambo (2005) To explore and describe perceptions of teenage pregnancy 32 39 female. 4 male Aged 15–24 years Education – secondary (4).com/content/6/1/3 Table 4: Characteristics of the studies included in the data synthesis Study Author (date) Aim Sample size Sample characteristics Context/setting Data collection Castle (2003) To investigate the belief that hormonal contraceptives lead to long-term sterility 75 (+ 8 health professionals) To learn about Tanzanians' opinions. 10 male Aged 13–19 years Education not reported Marital status not reported At least 10 females sexually active* (sampled from ante/ post-natal clinics) Bushbuckridge district of Limpopo Province. 6:3 http://www. Vietnam (urban) Hospital based sample (had experienced abortion) Individual interviews Otoide. Mali (urban) Mix of clients of peer education programme. waitresses or engaged in petty trade) All sexually active All unmarried 22 female. none/primary (15). primary (7).reproductive-health-journal. and a Love-Life Youth Centre Individual interviews Focus group discussions Page 6 of 12 (page number not for citation purposes) . Oronsaye & Okonofua (2001) To examine attitudes and beliefs of abortion and contraception 149 in 20 FGD Benin City. and nonclients from same areas 9 villages in 6 districts of Tanzania (Kisarawe. Dodoma.Reproductive Health 2009. 36 male Most aged 15–19 years* Most educated (14 of 52 clients/non-clients had no formal education) Most sexually active* Most unmarried* 63 male and 78 female Aged 15–19 yrs All participants had either some primary schooling or no schooling at all Most not sexually active* Most unmarried* 12 female. Sumbawanga. high school (5) and college/university (7) Females – all unmarried & all sexually active All female Aged 15–24 years Education – tertiary (23). peer educators. Mwanga.

page 79) [42]. Oronsaye & Okonofua (2001) Rasch et al (2000) Richter & Mlambo (2005) Wood & Jewkes (2006) ✓ X ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ X ✓ ✓ ✓ ✓ X ✓ ✓ ✓ X ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ X X ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ X X ✓ X ✓ ✓ X ✓ ✓ ✓ X ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ – Theme addressed in the paper.com/content/6/1/3 Table 4: Characteristics of the studies included in the data synthesis (Continued) Wood & Jewkes (2006) To collect information to improve access to and quality of contraceptive services for adolescent girls 35 (interviews) & 5 FGD (+ 14 nurses – interviews & focus groups) All female Aged 14–20 years Education not reported 33 interviewees were sexually active† All interviewees were unmarried† Limpopo Province. The expense could also be prohibitive. if you enter any chemist you will get family planning. Liamputtong & Murphy (2006) Otoide. Table 5: Limits to use of modern contraceptive methods: themes identified in the papers in the synthesis Misperception of pregnancy risk Knowledge of modern contraceptive methods Reliance on traditional contraceptive methods or abortion Access to modern contraceptive methods Concerns over side effects of modern contraceptive methods Desire of pregnancy/fertility proof Partner influence/ control Unplanned/forced sex Social/economic influences and pressures Threat to reputation Castle (2003) Kiluvia & Tembele (1991) Nguyen. Given the reported barriers to service use... Although these outlets were thought more discreet and confidential.Reproductive Health 2009. contraceptive provision was unlikely to be accompanied by accurate information on use or side effects [42].needed all her money for her daily needs" (Page 58) [39].]" (16 year old out of school female. [Why would someone go to a tertiary care centre in the city because of contraception? If you enter any patent medicine store you will get contraceptives. Nigeria. Page 7 of 12 (page number not for citation purposes) .reproductive-health-journal. 6:3 http://www. ". South Africa (semi-rural) Sample from semirural areas surrounding the main town – recruited from clinic waiting rooms or schools* Individual interviews and focus group discussions * Actual figures not reported. † Not reported for focus groups. and one study described how Anna (Tanzania). X – Theme was not addressed in the paper. access to contraceptives was therefore often through unofficial or commercial channels: "How person go dey go UBTH because of family planning.

page 406) [41]. but if you use NurIsterate [injection]. 2. and use violence to get young women not to use contraception [39.43. the blood can get out. Vietnam.44]..43] suggested that some young women wanted to become pregnant as a bargaining tool to solidify relationships: "I fell pregnant because I wanted my boyfriend to marry me. but others reported that their partners wanted them to get pregnant to prove the partners' fertility. But I did not know very well about this issue.41. force." (Ha. which were available from numerous sources. Some of the girls interviewed by Wood and Jewkes [44] reported being encouraged by their male partners to use contraception. I knew many contraceptive methods. But using them was up to my boyfriend.43. page 411) [41]. Nigeria. page 66) [43]. However." (20 year old female youth club member. it is more appropriate because with the condom there is no possibility of a mistake. partners' control over contraceptive use appeared strong when they provided gifts or money in exchange for sex [43].reproductive-health-journal. were central to young women's non-use of these. Partner relationships. they were not the contraceptive method most would opt for because they were more often thought to be for HIV/STI prevention. In Mali and South Africa. 6:3 Condoms.43]: "I asked my boyfriend to use condoms but he did not accept it. He did not like using them. Mali. physical violence to enforce this. This was particularly the case with condoms. were also considered to be an appropriate and accessible modern method by some young women: "If the partner of the girl likes using the condom.women who use contraceptives will find it difficult to conceive when they eventually get married. Fear of infertility was the most often cited: "." (Young woman. two African studies [39." (Young woman. For many. at times threatening to use. 19 year old college student. In South Africa.. particularly by going to a clinic.44].44]. 4. and it means your body will never be as it was before. South Africa. or tearing up the clinic card and throwing away the pills. and was linked to being promiscuous or a prostitute [39-41. and if you don't conceive that month. Hormonal contraceptive side effects. partner control over other contraceptive methods was also apparent [40. South Africa.. 3.41." (Young woman. or using." (18 year old woman with secondary schooling. page 64) [43]. this blood doesn't pass easily to the place next to the womb. page 190) [38].. However. Wood and Jewkes state: "Some boyfriends reportedly demanded that contraception be stopped.41. Therefore. methods which interrupted the perceived natural pattern of menstruation were unacceptable: "If you're not on the injection the blood stays somewhere next to the womb. I had to follow him. Partners were reported to manipulate.Reproductive Health 2009.. The side effects of hormonal contraceptive methods also constituted a significant threat to personal reputation: Page 8 of 12 (page number not for citation purposes) . Reputations and social status All the studies identified young women's reputations and social status as a limit to contraceptive use. constituted a public admission of having had sex. menstruation represented the womb being cleared of "dirt" [38. menstrual disruption and fertility fears All the studies showed that concerns over experienced and perceived side effects of hormonal contraceptive methods. Vietnam. particularly menstrual disruption.44]. threaten. sex and pressure All of the studies made reference to partners' attitudes towards contraception. and this blood prevents you from ever falling pregnant. However. The synthesis indicates that there was considerable social disapproval of premarital sex and pregnancy: "Community members do not accept teenage pregnancy they even scold us randomly when they meet a pregnant girl. access is easy. and was equated with good health [38. which were often crucial.44].. accessing contraceptives. 18 year old female high school student. South Africa." (Cuc. page 80) [42]. and he used withdrawal." (page 111) [44]. page 113) [44]. I just knew that condoms were used mainly for preventing from getting AIDS. and the price is affordable.com/content/6/1/3 want to use because they reduced sexual pleasure [39. which some of the young women's partners did not http://www. not pregnancy prevention: "People said that using condoms was to prevent getting pregnant.

Reliance on traditional contraceptive methods and abortion As a result of the difficulties with modern contraceptive methods discussed above young women were more likely to rely on traditional methods." (19 year old female with Franco-Arabic schooling. This was reinforced by the young women's partners.reproductive-health-journal. concerns about which led to a fear of being "condemned" (Page 111) [44]. In one study.Reproductive Health 2009. although these have not focused exclusively on adolescents or qualitative research.45]. In one study. although differences between these have previously been reported [9. This is similar to findings reported elsewhere in a larger review of young people's sexual behaviour [15]. Tanzania and South Africa) and one in SouthEast Asia (Vietnam).12. Relying on traditional methods provided greater privacy: "In using modern methods. were not thought as serious. Despite the expressed disapproval of premarital sexual activity. If you have a co-wife. There were also commonalities across urban and rural locations and across education levels (where reported). Fur- Page 9 of 12 (page number not for citation purposes) . Tanzania. Asia and Oceania) should be noted." (19 year old young women at university. one has to go to UMATI [Family Planning Association of Tanzania] and many people will know. especially fear of infertility. the studies in this review specifically focused on modern methods. The findings of the South-East Asian study were largely consistent with those from sub-Saharan Africa.. future social status was highly dependent on future fertility. especially if you have a mother-in-law who wants grandchildren. page 195) [38].many girls say this. even though illegal (in these countries and Mali abortion is only permitted to save a woman's life). However. such as periodic abstinence. which centre on lack of knowledge. She fit use quinine. Nigeria. or charms and herbal mixtures from traditional healers [40-42. page 80) [42]. the limited geographical range of the studies in this review and the lack of comparable research in this field from others areas (particularly from Central and South America.46-49].. Nigeria. [How can a women avoid pregnancy? There are many ways. This is similar to findings elsewhere [11. and similarities are apparent in other South American and South Asian studies [11. and lack of control. Use of hormonal methods was limited because of lack of knowledge and access and concern over side effects..42]. and sometimes more attractive than hormonal methods. it is important to note that the review is limited to five countries.45]. as those of modern contraceptive methods: "One D and C [abortion] is safer than 16 packs of daily pills. http://www. use of condoms was limited by their association with disease and promiscuity and greater male control of this method." (22 year old female undergraduate. obstacles to access. page 10) [40]. in Tanzania and Nigeria abortion was recognised as a fertility control option if an unintended pregnancy occurred [39. their parents and wider society: " [If you are thought to be infertile] you won't be loved. particularly among less educated women who often lacked alternatives [43.. She can take quinine (antimalarial drug).44]. 6:3 "It [amenorrhea] is abnormal." (Female in 15–19 years age group. As a result young women often relied on traditional methods or abortion. and the threat to fertility it incurred. In both West and Southern Africa. In South Africa. page 79) [42]. Mali. However. There are men who follow their parents blindly. he will do it without even thinking. Our findings are also strengthened by the inclusion of only methodologically rigorous studies: five papers had to be excluded for not reporting enough original data to support their findings.. getting pregnant offered definitive proof of childbearing potential. so use of traditional methods was not discussed in detail. we do not mean to suggest that conditions will be homogenous for all young women in all developing countries. the potential side effects of abortion. or as likely. this was one of the few available means of attaining respected status [44]. When a woman cannot have children she is called a lot of names like "whore" and people say that she must have had a lot of abortions. If in your marriage you have a mother-in-law who asks her son to divorce you. Nigeria. However.]. page 195) [38].. Although often more accessible. This paper adds to the literature by demonstrating that the limits could be common across very different settings and contexts. Discussion This systematic review of qualitative research demonstrates that young women's use of modern contraceptive methods in five developing countries is limited by a range of factors. 5. while in using local herbs it's one's own secret. at every opportunity she will boast that she has children and you don't. four in sub-Saharan Africa (Mail. withdrawal. even common medicines such as aspirin or antibiotics were thought effective contraceptives: "How woman fit prevent belle? Na many ways. Although the overarching themes were common across all locations and settings." (17 year old uneducated female hairdresser.com/content/6/1/3 Alternatively. Mali.44].

Qualitative research terms have been successfully incorporated into review search strategies [27]. pro- Page 10 of 12 (page number not for citation purposes) . sometimes coercive. So for young women. conversely. choice or discontinuation of contraceptives.12. for whom the health risks and consequences of unplanned pregnancy are of particular concern [2]. Young women are under pressure to remain fertile so that they can bear children. and condoms and traditional methods. Bearing children is necessary to be respected within their husband's family. particularly in the areas of teenage pregnancy and childbearing. but condoms were often considered accessible. limits young women's knowledge of.54].com/content/6/1/3 the future. Use of modern contraceptive methods has been successfully promoted for child spacing and limiting family size among older married women with children in developing countries [1. and secondly. Our search strategy used an extensive range of search terms (see Table 1) and identified almost 20000 references. efforts to increase the uptake of modern contraceptives require detailed understanding of the barriers to this. are relied on. particularly when sex is accompanied by financial or material reward [50.45]. This highlights the need to include both sexes in sexual and reproductive health interventions [57]. and provide economic support or insurance for http://www. After an initial review of these for relevance on contraceptive use. particularly when young women are still at school.43]. In addition. 8% in Nigeria and 17% in Tanzania) [55]. However. support and access to youth-friendly services for adolescents [5. which have been missed (although our strategy did include searches of the Copac Academic & National Library and the British Library Catalogues.41. particularly in relation to condom use. It is questionable that attempts to increase use of modern methods among adolescents will be effective in countries where they remain unacceptable to older married women. unmarried women.45.56]. 6:3 ther research is necessary to examine the restrictions on contraceptive use in these areas. in the remaining three African countries. role that men have in contraceptive decisions is apparent [12. but we are doubtful that this is the case. Misconceptions of modern hormonal methods. the considerable. uptake is high (55% and 57% of currently married 15–49 year old women report using a modern method respectively) [55].52]. uptake is low (7% in Mali. on which most exclusions were based. The findings from young men. Also.45. preserving future fertility becomes as important as preventing pregnancy. protect from divorce. This was also the case in the studies we reviewed. 4000 references were specifically screened: firstly for direct relevance to the review question. Although this paper focused on women. but we did not use these because we originally planned to include quantitative research. In two of the countries in this review (South Africa and Vietnam). as is provided by the studies included in this review. we concede that the exclusion of non-English language studies could have missed some relevant papers. However. and challenging inaccurate beliefs and cultural norms around fertility at the communitylevel. will require the provision of more targeted promotion of life skills.40. It is possible that a more specific search strategy could have identified further qualitative papers of direct relevance to the review question.Reproductive Health 2009. It is also important to note that our review is limited to a small number of papers and to ask whether we succeeded in identifying all relevant qualitative research. Increasing uptake among all women will require countering the negative perceptions of modern contraceptive methods.50].49. Even abortion was sometimes viewed as more appropriate for a few of the young women in this review. not being able to bear children poses a significant threat to social and economic survival [11. Promotion of modern contraceptives requires multifaceted interventions at all levels of society. Such beliefs are often reported to be communitywide [11. Studies show that social disapproval of premarital sex.53]. as well as attempts to source grey literature from the websites of relevant organisations such as the WHO and the Population Council). where included in the studies reviewed here. could have touched upon such issues but been excluded from the review because of this criterion (or because the study abstract. were common among the young women in this review. our inclusion criteria required that at least one quarter of the study's results were on uptake. particularly that their use could cause infertility. did not refer specifically to contraception). health services [12. and in some cases more attractive than other modern contraceptive methods. increasing uptake among young. and access to. once it is socially acceptable to do so. 17% in Nigeria and 22% in Tanzania) [55]. it could be seen as more accessible (and less risky) than accessing or using hormonal contraceptives [52.51]. Contraceptive choice among the young women in the African and Vietnamese studies in this review was restricted by their concerns about fertility and their status as women. It is possible that further studies. However. The role of HIV/STIs in young women's sexual attitudes and experiences was beyond the scope of this review. Although illegal and dangerous in most sub-Saharan African countries. but there is still considerable variation between countries. and that there could be further qualitative studies published in books or the grey literature. use (or non-use).reproductive-health-journal. which do not threaten fertility.12]. confirmed those obtained from the perspectives of young women [38. even though their association with disease. for qualitative research. despite evidence of unmet need (29% in Mali.48.

Sex Education 2005. Blanc AK: The changing context of sexual initiation in sub-Saharan Africa. Opportunities for intervention are apparent. Smith JA: The problem of appraising qualitative research. Barbour M: Evaluating and synthesizing qualitative research: the need to develop a distinctive approach. in particular limited knowledge. and the dual pregnancy and HIV prevention role of this method should be capitalised on. and commercial sex can limit use [12. Given women's concern with future fertility. Sieving RE. No. and should be capitalised on. 49. Agarwal S. Woog V: Evaluating the need for sex education in developing countries: sexual behaviour. it should be stressed that it can be enhanced by protecting against STIs. Sahin-Hodoglugil NN. LW prepared the first draft of the paper. which should aim to counter negative perceptions of modern methods. Baum F: Researching public health: behind the qualitativequantitative methodological debate. Jones D.15. et al. Increasing modern contraceptive method use requires community-wide. our finding that major limits to modern contraceptive use could be common across various settings. 10:45-53. Grant MJ. Plummer ML. Bernstein S. 322:1115-1117. the consequences of not improving access to modern contraceptive methods are dire. 9:179-186. Dixon-Woods M. access.61]. 368:1810-1827. However. 2. Gage AJ: Sexual activity and contraceptive use: the components of the decisionmaking process. Wight D. Mavranezouli I. Agarwal S. worries about fertility and the low status of women. reproductive health and the global effort to end poverty New York: UNFPA. 5. multifaceted interventions. 7. 12. 17. 16. this systematic review of qualitative research suggests that similar factors restrict young women's contraceptive choices across different developing countries. Fear of unwanted pregnancy may be as much a motivation for condom use as fear of AIDS [59]. 32:699-727. Global variations in sexual behaviour exist and no one sexual or reproductive health intervention will work everywhere [63].2]. Authors' contributions LW.00. Young B. Contraception 2008. Rev.45. 13:223-225. We thank Val Hamilton and Vittoria Lutje for conducting the literature searches. Ferguson J. 2004. child mortality and poverty [1. and the clear role of improving reproductive health in achieving the Millennium Development Goals on maternal health. Blum RW: Youth in sub-Saharan Africa. 2008. and conducted the data synthesis. Reprod Health Matters 2006. Qual Saf Health Care 2004. 21. Changalucha J. married young women in sub-Saharan Africa: the big picture. Acknowledgements Funded by the UK Medical Research Council as part of the Sexual and Reproductive Health Programme (WBS U. knowledge of preventing sexually transmitted infections/HIV and unplanned pregnancy. Cleland J. but their promotion for pregnancy prevention should also be actively encouraged. Bearinger LH. 7:125-133. as has use among young. The promotion of condoms for HIV and STI prevention is essential. The Cairo consensus at ten: population. and potential. prevention. 18. Dixon-Woods M.57]. Fitzpatrick R.Reproductive Health 2009. Innis J: Family planning: the unfinished agenda. 8. 6:3 miscuity. 80(suppl II):ii49-ii56. Lancet 2006. 4 [http://unstats. 4. Competing interests The authors declare that they have no competing interests. Mshana G. 368:1581-1586. Bankole A. Lancet 2006. Potts M: Barriers to fertility regulation: a review of the literature. 40:459-468. Popul Dev Rev 2006. Mensch BS. McGinn E: Unintended pregnancy in sub-Saharan Africa: magnitude of the problem and potential role of contraceptive implants to alleviate it. 78:73-78. LW and AP critically appraised and reviewed papers for inclusion in the review. Conclusion Although limited to five countries. 6. http://www. 369:1220-1231. Shah I: Trends in protective behaviour among single vs. To date. 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